Black Cohosh — Actaea racemosa

Common & Latin Names

Common names: Black cohosh, Black snakeroot, Bugbane, Rattleweed, Macrotys, Squaw root (deprecated — this term is considered culturally inappropriate) Latin name: Actaea racemosa L. (synonym: Cimicifuga racemosa (L.) Nutt. — the older name still widely used in clinical literature) TCM name: Sheng Ma (升麻) — refers primarily to Cimicifuga foetida/dahurica in classical TCM, but A. racemosa is used in modern integrative practice German: Traubensilberkerze (grape silver candle — referring to the flower spike)

Plant Family & Parts Used

Family: Ranunculaceae (buttercup family — also includes goldenseal, Coptis, aconite, clematis) Parts used: Rhizome and roots. Harvested in autumn after the aerial parts die back, when the underground parts are richest in active compounds. The root system is dense, dark (hence “black”), and has a distinctly unpleasant bitter taste. Habitat: Native to eastern North America — from southern Ontario and Quebec, south through the Appalachian Mountains to Georgia, west to Missouri and Arkansas. Grows in rich, moist deciduous forests, woodland edges, and shaded ravines. A woodland shade plant reaching 1-2.5 meters in height with dramatic tall spikes of white flowers (candle-like racemes) in late spring.

Conservation note: Black cohosh is at risk from overharvesting due to global demand for menopause preparations. The United Plant Savers organization lists it as “At Risk.” Cultivated sources should be preferred. The American Herbal Products Association (AHPA) has issued sustainability guidelines.

Traditional Uses

Native American Medicine (Primary Tradition)

Black cohosh was one of the most valued medicinal plants of the Eastern Woodland peoples:

• Cherokee: Used the root for rheumatism, kidney trouble, malaise, sore throat, and as an infusion to ease childbirth. The root decoction was used for “female complaints” including menstrual irregularity and menopausal symptoms.
• Iroquois (Haudenosaunee): Root decoction for rheumatism and to promote menstruation. Also used as a wash for sore back and joints.
• Delaware (Lenape): Root infusion for kidney ailments and rheumatism.
• Algonquin peoples: For gynecological complaints, snakebite (hence “snakeroot”), and to repel insects (hence “bugbane”).

The name “cohosh” derives from an Algonquin word meaning “rough” (referring to the root’s texture). The strong association with women’s health across multiple independent tribes is significant — it represents convergent clinical observation of the plant’s gynecological specificity.

Eclectic Medicine (19th Century)

Black cohosh was adopted enthusiastically by the American Eclectic physicians after learning of its use from Native Americans. John King introduced Macrotys (Cimicifuga) to Eclectic medicine in 1844. It became one of the signature Eclectic remedies:

• Dysmenorrhea (painful menstruation) — considered a specific remedy
• Amenorrhea and menstrual irregularity
• Menopausal symptoms (“change of life” complaints)
• Rheumatism and neuralgia (particularly “ovarian neuralgia” and sciatica)
• Chorea (involuntary movements)
• Depression and “hysterical” states associated with the reproductive cycle

The Eclectic understanding was remarkably prescient: they observed that black cohosh worked best when reproductive and musculoskeletal symptoms coexisted — a pattern we now recognize as the estrogen withdrawal syndrome of menopause.

German Phytomedicine (20th Century)

Like vitex, black cohosh was adopted and developed by German pharmaceutical companies. Schaper & Brummer developed the first standardized extract (Remifemin) in the 1950s. Commission E approved black cohosh for “premenstrual complaints, dysmenorrhea, or menopausal neurovegetative complaints” in 1989. Germany has produced the bulk of clinical research.

Active Compounds & Pharmacology

Primary Phytochemicals

Triterpene glycosides (the primary active compound group):

• Actein (27-deoxyactein): The most abundant and most studied triterpene glycoside. Used as the standardization marker for most commercial extracts (typically standardized to 2.5% triterpene glycosides).
• Cimicifugoside: Anti-inflammatory and analgesic.
• 23-epi-26-deoxyactein: Anti-proliferative (relevant to cancer safety data).
• Cimiracemoside A and B: Immunomodulatory.

Phenylpropanoids:

• Fukinolic acid: A caffeic acid derivative unique to Actaea/Cimicifuga species. Anti-inflammatory.
• Cimicifugic acids A-F: Hydroxycinnamic acid derivatives with serotonergic and dopaminergic activity.
• Isoferulic acid: Anti-inflammatory, analgesic.

Flavonoids: Formononetin (an isoflavone — present in trace amounts, contributing to the early “phytoestrogen” hypothesis that has since been revised).

N-omega-methylserotonin: A serotonin derivative found in black cohosh — potentially contributes to hot flash reduction via central serotonergic mechanisms.

Alkaloids: Cimipronidine (a guanidine alkaloid unique to Cimicifuga), with dopaminergic activity.

Mechanisms of Action

1. Central Serotonergic Activity: The current leading hypothesis for black cohosh’s hot flash reduction. The N-omega-methylserotonin and cimicifugic acids bind to serotonin receptors (5-HT1A, 5-HT1D, and 5-HT7) in the hypothalamic thermoregulatory center. Hot flashes are primarily driven by narrowing of the thermoneutral zone in the hypothalamus — serotonergic modulation widens this zone, reducing flash frequency and severity. This mechanism is analogous to venlafaxine (an SNRI) and paroxetine, both of which are FDA-approved for hot flashes.

2. Dopaminergic Activity: Black cohosh compounds bind to dopamine D2 receptors, contributing to prolactin regulation and mood effects. This is similar to (but weaker than) vitex’s dopaminergic mechanism.

3. NOT Estrogenic (Revised Understanding): Early studies hypothesized that black cohosh worked through estrogen receptor binding (the “phytoestrogen hypothesis”). This has been extensively investigated and largely disproven. Black cohosh does NOT bind estrogen receptors alpha or beta at clinically relevant concentrations. It does not increase circulating estrogen. It does not stimulate estrogen-dependent breast or uterine tissue. Multiple studies (Bai et al., 2007; Ruhlen et al., 2008) have confirmed the absence of estrogenic activity. This is critically important for safety in breast cancer survivors.

4. Opioid Receptor Modulation: Some evidence for mu-opioid receptor activity, contributing to analgesic and mood effects.

5. Anti-inflammatory: Actein and related triterpenes inhibit NF-kB, reduce IL-6 and TNF-alpha, and modulate cyclooxygenase activity. This explains the traditional use for rheumatic conditions.

6. Bone-Protective Effects: In vitro and animal studies suggest black cohosh promotes osteoblast differentiation and inhibits osteoclast formation — relevant for postmenopausal bone loss. The mechanism is independent of estrogen receptor signaling.

Clinical Evidence

Key Clinical Trials

Shams, T., Setia, M.S., Hemmings, R., McCusker, J., Sewitch, M., & Ciampi, A. (2010). “Efficacy of black cohosh-containing preparations on menopausal symptoms: a meta-analysis.” Alternative Therapies in Health and Medicine, 16(1), 36-44.

• Meta-analysis of 9 RCTs examining black cohosh for menopausal symptoms
• Pooled analysis demonstrated a significant 26% reduction in menopausal symptom severity (weighted mean difference: -1.98 on the Kupperman Menopause Index, p=0.027)
• Most consistent effects on vasomotor symptoms (hot flashes, night sweats) and mood symptoms
• Efficacy was most pronounced in the isopropanolic extract (Remifemin) at 40mg daily
• Concluded that “black cohosh may be effective for menopausal symptoms, particularly vasomotor symptoms”

Bai, W., Henneicke-von Zepelin, H.H., Wang, S., et al. (2007). “Efficacy and tolerability of a medicinal product containing an isopropanolic black cohosh extract in Chinese women with menopausal symptoms: a randomized, double-blind, parallel-controlled study versus tibolone.” Maturitas, 58(1), 31-41.

• 244 Chinese menopausal women, isopropanolic black cohosh extract (iCR) 40mg daily vs. tibolone (a synthetic steroid used for menopause) for 3 months
• Black cohosh was as effective as tibolone in reducing menopausal symptoms (Kupperman Index reduction: equivalent between groups)
• Black cohosh was better tolerated than tibolone
• Critically: black cohosh did NOT affect endometrial thickness, vaginal cytology, or hormone levels (estradiol, FSH, LH) — confirming non-estrogenic mechanism
• This study is pivotal because it demonstrated equivalence to a pharmaceutical in a large, rigorous trial AND confirmed the absence of estrogenic effects

Osmers, R., Friede, M., Liske, E., et al. (2005). “Efficacy and safety of isopropanolic black cohosh extract for climacteric symptoms.” Obstetrics & Gynecology, 105(5 Pt 1), 1074-1083.

• 304 women with menopausal complaints, iCR 40mg daily vs. placebo for 12 weeks
• Significant reduction in Menopause Rating Scale (MRS) total score (p<0.001)
• Significant improvements in hot flashes, sweating, sleep disturbance, and depressive mood
• Well-tolerated with adverse events comparable to placebo

Wuttke, W., Seidlova-Wuttke, D., & Gorkow, C. (2003). “The Cimicifuga preparation BNO 1055 vs. conjugated estrogens in a double-blind placebo-controlled study: effects on menopause symptoms and bone markers.” Maturitas, 44(Suppl 1), S67-S77.

• Compared black cohosh extract, conjugated estrogens, and placebo in menopausal women
• Black cohosh was equivalent to conjugated estrogens in reducing hot flashes
• Unlike estrogens, black cohosh did not stimulate endometrial tissue
• Interestingly, black cohosh improved bone markers (osteocalcin, CrossLaps) — suggesting bone-protective effects independent of estrogen

Therapeutic Applications

Conditions

• Menopausal vasomotor symptoms: Hot flashes and night sweats (strongest evidence base)
• Menopausal mood symptoms: Depression, anxiety, irritability during menopause transition
• Menopausal sleep disturbance: Commonly reported improvement in clinical trials
• Dysmenorrhea: Traditional use supported by anti-inflammatory mechanism
• Premenstrual symptoms: Limited but positive evidence
• Musculoskeletal pain in menopause: Rheumatic and neuralgic pain associated with estrogen decline
• Postmenopausal bone health (adjunctive): Preliminary evidence for bone-protective effects
• Breast cancer survivors with menopausal symptoms: Non-estrogenic mechanism makes it suitable for women who cannot use HRT

Dosage Ranges

• Isopropanolic extract (iCR, Remifemin): 40mg daily (standardized to 2.5% triterpene glycosides, calculated as actein). This is the most-studied form.
• Ethanolic extract (BNO 1055): 40mg daily
• Dried rhizome/root: 40-200mg daily in capsules
• Decoction: 0.3-2g dried root simmered in water for 10-15 minutes, 3 times daily
• Tincture (1:10 in 60% alcohol): 0.4-2mL, 2-3 times daily
• Liquid extract (1:1): 0.3-2mL daily

Forms and Duration

Standardized extracts (iCR/Remifemin) are preferred for clinical use due to consistent dosing and the largest evidence base. Effects on hot flashes typically begin within 4-8 weeks, with full effects at 12 weeks. German guidelines recommend use for up to 6 months initially, with reassessment. Extended use beyond 6 months is common in clinical practice and appears safe based on available data.

Safety & Contraindications

Generally Well Tolerated

In clinical trials involving thousands of menopausal women, adverse events with black cohosh are comparable to placebo. The most common side effects are mild GI discomfort (5-7%) and headache (4-5%).

The Hepatotoxicity Debate

Reports of liver injury attributed to black cohosh have generated significant regulatory attention:

• Between 2002-2012, approximately 83 case reports of liver injury “associated” with black cohosh were published globally
• Critical analysis reveals: most cases involved multi-ingredient products (making attribution impossible), many patients had pre-existing liver conditions, several cases were caused by adulterated products (containing other Actaea species or unrelated herbs), and causality was confirmed in very few cases
• The National Institutes of Health Liver Tox database classifies black cohosh hepatotoxicity as “rare” and “idiosyncratic”
• Pharmacovigilance data from Germany (where millions of doses have been consumed) shows an estimated hepatotoxicity incidence of <1 per million patient-years
• In response, regulatory bodies in Australia, the UK, and Canada now require label warnings, while the German Medicines Agency (BfArM) considers the benefit-risk profile favorable

Practical guidance: Monitor liver enzymes at baseline and at 3-6 months in patients with pre-existing liver conditions. Discontinue if liver symptoms (jaundice, dark urine, abdominal pain) develop. In patients with normal liver function, the risk is extremely low.

Contraindications

• Liver disease: Use with caution and monitoring in patients with active liver conditions.
• Pregnancy: Contraindicated — black cohosh has uterotonic properties and was traditionally used to facilitate labor. Not appropriate during pregnancy except under practitioner supervision in late pregnancy for labor preparation.
• Lactation: Insufficient data. Generally avoided.
• Estrogen receptor-positive breast cancer: Despite the non-estrogenic mechanism, some oncologists prefer to avoid any hormonal-adjacent interventions. However, the evidence actually supports safety — Ruhlen et al. (2008) demonstrated no estrogenic effects, and retrospective studies show no increased breast cancer risk.

Drug Interactions

• Hepatotoxic drugs: Additive liver risk (theoretical). Monitor when combined with statins, acetaminophen, or other hepatotoxic medications.
• Tamoxifen/aromatase inhibitors: No pharmacokinetic interaction demonstrated. The non-estrogenic mechanism suggests compatibility, but consult with the oncology team.
• CYP2D6 substrates: Black cohosh weakly inhibits CYP2D6. Clinical significance is low but monitor with tamoxifen (which requires CYP2D6 activation).
• Antihypertensives: Black cohosh may have mild hypotensive effects. Monitor.

Side Effects

GI discomfort (most common), headache, dizziness, breast tenderness (rare), and weight gain (rare). Rash and allergic reactions are very rare. Vaginal spotting has been reported occasionally.

Energetics

TCM Classification

The closely related Sheng Ma (Cimicifuga foetida/dahurica) in classical TCM is classified as:

• Temperature: Cool to cold
• Flavor: Sweet, acrid, slightly bitter
• Meridian entry: Lung, Spleen, Stomach, Large Intestine
• Actions: Releases the exterior, clears heat, raises Yang Qi (lifts prolapse), guides other herbs upward

For Actaea racemosa specifically (modern integration):

• Temperature: Cool
• Flavor: Bitter, acrid
• Meridian entry: Liver, Kidney, Ren (Conception Vessel)
• Actions: Clears heat from the blood level, calms the Shen, nourishes Yin, cools menopausal fire (Yin-deficiency heat), moves Blood stagnation in the Lower Jiao
• TCM pattern correspondence: Kidney Yin deficiency with empty heat (menopausal hot flashes, night sweats, insomnia), Liver Blood stagnation (dysmenorrhea), Liver Qi stagnation with heat (irritability, mood swings)

Ayurvedic Classification

• Rasa (taste): Tikta (bitter), Kashaya (astringent)
• Virya (energy/potency): Shita (cooling)
• Vipaka (post-digestive effect): Katu (pungent)
• Dosha effects: Strongly pacifies Pitta (cooling, calming excess heat). Pacifies Vata (calming nervous system). May increase Kapha in excess due to its heavy, cooling nature.
• Dhatu affinity: Rakta (blood), Asthi (bone), Shukra (reproductive), Majja (nerve/marrow)
• Srotas affinity: Artavavaha (menstrual/reproductive), Asthivaha (bone), Raktavaha (blood)

Functional Medicine Integration

Black cohosh is the most evidence-based botanical for menopausal vasomotor symptoms and occupies a central role in functional medicine menopause protocols.

Menopause Protocol (Non-Hormonal)

For women who cannot or choose not to use hormone replacement therapy, black cohosh is the first-line botanical for hot flashes and night sweats. Its non-estrogenic mechanism (central serotonergic and dopaminergic modulation) makes it appropriate for women with contraindications to estrogen, including breast cancer survivors. In comprehensive menopause protocols, it is combined with maca (for libido and mood), dong quai (for Blood nourishment), and adrenal adaptogens (ashwagandha, rhodiola) for stress resilience.

Breast Cancer Survivorship Protocol

Menopausal symptoms are often severe in breast cancer survivors due to abrupt estrogen withdrawal (surgical menopause, aromatase inhibitors, tamoxifen). Black cohosh provides symptom relief without estrogenic stimulation. The Bai et al. (2007) and multiple safety studies support its use in this population.

Musculoskeletal Pain in Menopause

The Eclectic physicians’ observation that black cohosh addresses both gynecological and musculoskeletal symptoms simultaneously is validated by modern understanding. Estrogen decline drives both vasomotor symptoms and joint/muscle pain. Black cohosh’s anti-inflammatory triterpenes address the musculoskeletal component while its central serotonergic effects address hot flashes. This dual action is valuable for the common menopause presentation of hot flashes WITH joint pain.

Mood and Sleep in Menopause

The serotonergic and dopaminergic activity of black cohosh explains the consistent improvements in mood and sleep seen in clinical trials. For women experiencing the menopause “triad” of hot flashes + mood disturbance + insomnia, black cohosh can address all three through a single mechanism.

Four Directions Connection

Primary Direction: Jaguar (West — Emotional Healing)

Black cohosh is profoundly Jaguar medicine. Menopause is the great transition — the threshold between the reproductive years and the wisdom years, the death of one identity and the birth of another. The Jaguar guards this threshold. The emotional turbulence of menopause — grief, rage, anxiety, loss of identity, confrontation with aging and mortality — belongs to the Jaguar’s domain. Black cohosh soothes the fires of this transition without suppressing it. It allows women to walk through the Jaguar’s gateway with less suffering but no less transformation. The hot flash itself is a Jaguar experience — a sudden wave of heat and emotion that cannot be controlled or predicted, forcing the woman into present-moment awareness.

Secondary Direction: Serpent (South — Physical Body)

The physical symptoms of menopause — vasomotor instability, joint pain, bone loss, sleep disruption — are Serpent territory. Black cohosh addresses the body’s distress during the hormonal shift, supporting the physical adaptation to a new hormonal reality. The Serpent sheds its skin; the menopausal woman sheds her reproductive physiology. Black cohosh eases this shedding.

Tertiary: Eagle (East — Spiritual Vision)

Menopause, in many Indigenous traditions, is the time when a woman receives her full spiritual power — she becomes a “keeper of wisdom.” The Eagle’s domain is spiritual vision and perspective. By easing the suffering of the menopausal transition, black cohosh allows women to focus on the spiritual opportunity that menopause represents rather than being consumed by physical distress. The traditional Algonquin women who used black cohosh during this transition understood that the body must be settled before the spirit can ascend.

References

1. Shams, T., Setia, M.S., Hemmings, R., McCusker, J., Sewitch, M., & Ciampi, A. (2010). Efficacy of black cohosh-containing preparations on menopausal symptoms: a meta-analysis. Alternative Therapies in Health and Medicine, 16(1), 36-44.

2. Bai, W., Henneicke-von Zepelin, H.H., Wang, S., et al. (2007). Efficacy and tolerability of a medicinal product containing an isopropanolic black cohosh extract in Chinese women with menopausal symptoms. Maturitas, 58(1), 31-41.

3. Osmers, R., Friede, M., Liske, E., et al. (2005). Efficacy and safety of isopropanolic black cohosh extract for climacteric symptoms. Obstetrics & Gynecology, 105(5 Pt 1), 1074-1083.

4. Wuttke, W., Seidlova-Wuttke, D., & Gorkow, C. (2003). The Cimicifuga preparation BNO 1055 vs. conjugated estrogens in a double-blind placebo-controlled study. Maturitas, 44(Suppl 1), S67-S77.

5. Ruhlen, R.L., Sun, G.Y., & Sauter, E.R. (2008). Black cohosh: insights into its mechanism(s) of action. Integrative Medicine Insights, 3, 21-32.

6. Naser, B., Schnitker, J., Minber, M.J., et al. (2011). Suspected black cohosh hepatotoxicity: no evidence by meta-analysis of randomized controlled clinical trials for isopropanolic black cohosh extract. Menopause, 18(4), 366-375.

7. Borrelli, F., & Ernst, E. (2008). Black cohosh (Cimicifuga racemosa) for menopausal symptoms: a systematic review of its efficacy. Pharmacological Research, 58(1), 8-14.

8. Fabricant, D.S., Nikolic, D., Lankin, D.C., et al. (2005). Cimipronidine, a cyclic guanidine alkaloid from Cimicifuga racemosa. Journal of Natural Products, 68(8), 1266-1270.

9. Fritz, H., Seely, D., McGowan, J., et al. (2014). Black cohosh and breast cancer: a systematic review. Integrative Cancer Therapies, 13(1), 12-29.

10. Low Dog, T. (2005). Menopause: a review of botanical dietary supplements. American Journal of Medicine, 118(Suppl 12B), 98-108.